Forms

Providers

Providers, click here for prior authorizations, eiligibility status, and claim submission information.

BeniComp Select

• BeniComp Select Executive Medical Reimbursement - Online Application
• BeniComp Select Executive Medical Reimbursement - Submit a Claim
• BeniComp Select Executive Medical Reimbursement - Support Form

Self-Funded Groups

• Form W-9 - Request for Taxpayer Identification Number and Certification
• Transparency in Coverage (Machine Readable Files)

Health Screenings

• BeniComp Participant Appeal Form